Translation and adaptation study.
To translate and cross culturally adapt the Spinal Cord Injury Falls Concern Scale (SCI-FCS) English version into Thai, and to examine content validity, internal consistency and test-retest reliability.
A tertiary rehabilitation center in Thailand.
The SCI-FCS was translated into Thai and culturally translated according to guidelines for the process of cross-cultural adaptation of self-report measures. Content validity was examined by the Index of item-objective congruence (IOC). Moreover, internal consistency and test-retest reliability were tested by the Cronbach’s alpha coefficient and intraclass correlation coefficient (ICC) models (3, 1), respectively.
Three items were modified to accommodate cultural differences. After synthesis and cross adaptation, the IOC was 1.0. The Cronbach’s alpha coefficient was 0.88 (range 0.86–0.89) and the ICC of total scores was 0.99 (P < 0.001, range of the subitems 0.98–1). In addition, items that Thai participants scored as being the highest concern of falling were item 13: pushing wheelchair up/down gutters or curbs, item 14: pushing wheelchair up/down a slope, and item 12: pushing wheelchair on an uneven surface.
The SCI-FCS-Thai version is a reliable and valid outcome measure for assessing concern about falling in wheelchair users with SCI in Thailand.
Approximately 80% of individuals with spinal cord injury (SCI) depend on a wheelchair to complete their daily activities and participate with their environment . Falls and recurrent falls seem to be common with wheelchair users with SCI [2,3,4]. A meta-analysis study reported that 69% of wheelchair users with SCI fell more than once over 12 months . Falls for these individuals usually occurred while they were performing activities such as transferring, reaching, climbing the gutter, or propelling the wheelchair on even and uneven surfaces [2, 6]. Fall-related injuries and the negative consequences of falls can affect the individual socially and economically . Not only is physical health affected by falls, but the impact on psychological health is significant.
In Thailand, falling occurs in individuals with SCI after they discharge from the hospital. Amatachaya et al. in 2011  and Wannapakhe et al. in 2015  reported that 33 and 36% of participants with motor complete SCI who depend on a wheelchair fell within 6 months after they were discharged. Wannapakhe et al. found the falls mostly occurred while people with SCI were performing an activity in a wheelchair within and around the house, and some individuals had bruises and became unconscious after the fall . At present, there is a trend toward a decreased length of stay in hospitals in Thailand , which may negatively affect the functional abilities the individuals with SCI at the time of discharge. Thereafter, a lack of mobility and inadequate wheelchair skills for people with a sensorimotor deficit might distort their ability to move safely. The increased incidence of falls may have a negative psychological impact on wheelchair users, including an unwarranted fear of falling, low self-efficacy, self-restriction, activity limitation, and participation restriction, resulting in a reduced quality of life and/or increased dependency. Consequently, it is essential to address fall-related psychological affects in wheelchair users with SCI.
Boswell-Ruys et al. developed the Spinal Cord Injury Falls Concern Scale (SCI-FCS) in 2010 based on the Falls Efficacy Scale-International . This scale is the first outcome measure for wheelchair users with SCI to address concerns about falling that are related to psychological domains. The SCI-FCS consists of 16 activities that are related to daily living activities for a wheelchair user with SCI; for example, transferring in/out of bed, pushing a wheelchair on an uneven surface, and pushing a wheelchair up/down a slope . The SCI-FCS has been translated to other languages, including, Swedish, Norwegian, and Italian [10,11,12]. High psychometric properties of the SCI-FCS were presented in previous studies [9,10,11,12].
The SCI-FCS has not been translated into the Thai language. Information regarding falling concerns in individuals with SCI is lacking. Having a cross-cultural adaptation of the SCI-FCS into the Thai language is essential, not only for clinical practice, but also to develop comparable clinical studies internationally. The objective of the study was to translate and cross culturally adapt the SCI-FCS English version into the Thai language and to assess its content validity, internal consistency, and test-retest reliability.
Translation and cross-cultural adaptation process
The process of translation and cross-cultural adaptation from the English version into the Thai version was agreed to by the developers of the original version. This process was performed based on the guidelines of Beaton et al. in 2000  as follows. Stage I, forward translation: two bilingual translators who had different positions and backgrounds produced two independent translations. Stage II, synthesis of the translations: a synthesis of the two translations first was conducted to become the SCI-FCS-Thai version I by consensus of the researchers and translators. Stage III, back translation: two bilingual translators from the language institute translated the SCI-FCS-Thai version I back into the English language. The two back translators were different persons than the translators who participated in stage I. The back translators did not know the SCI-FCS before in order to avoid information bias. Back translation was performed to check that the translated Thai version was reflecting the same content as the original English version. Then, the SCI-FCS Thai version 2 was created. Stage IV, expert review: three experts who consisted of a bilingual professional, a physical therapist who had experience with individuals with SCI, and a rehabilitation physician reviewed all the translations and compared the Thai and English version. The experts then evaluated all content of the translated version. For each item, they were asked to determine a content validity score by reporting the Index of Item-Objective Congruence (IOC), using an ordinal scale of +1 (clear agreement), 0 (unclear) or −1 (no clear agreement). An average score of more than 0.5 is considered acceptable . Moreover, if some content was unclear, the experts gave a suggestion to adjust it with the environment and lifestyle of Thai individuals with SCI. Next, the researchers synthesized all of the data from the adapted version and sent the information of adapted items back to the author of the original version to approve. Then, assessment of the SCI-FCS-Thai prefinal version was conducted. Step V, test of prefinal version: 15 participants with SCI who used a manual wheelchair for at least 1 year were asked to complete the SCI-FCS prefinal Thai version to ensure that the adapted version still retained its equivalence to an applied situation.
Reliability and collecting data process
The translation validity and reliability process was conducted from December 2017 to April 2018. Participants were recruited from a tertiary rehabilitation center in Thailand. Inclusion criteria were individuals with incomplete or complete SCI who used a manual wheelchair as their primary source of mobility for performing daily living activities (for at least 75% of mobility needs) for at least 1 year, aged between 18 and 60 years and able to understand and speak Thai. Individuals were excluded if they had a level of injury (according to the International Standards for Neurological Classification of Spinal Cord Injury) above C5 or below L5 . Informed consent was obtained from all participants. All participants were interviewed demographic data were collected including age, gender, SCI characteristics, wheelchair experience, and history of falls. They were asked about concerns of falling by using the SCI-FCS Thai version twice within one week.
Descriptive statistics were used to illustrate the demographic and SCI characteristics of participants as well as the SCI-FCS score. Internal consistency was calculated using the Cronbach’s alpha coefficient. Good internal consistency was considered to have an alpha value of more than 0.7 . Test-retest reliability was examined using the ICC (3,1) which classified poor, moderate, good, and excellent following less than 0.50, 0.50–0.75, 0.75–0.90, and greater than 0.90, respectively . A P-value less than 0.05 was considered as a level of statistical significance.
Translation, cross-cultural adaptation process, and content validity
After the SCI-FCS Thai version was approved with the suggestions of the experts, three items were modified to accommodate cultural differences. Table 1 shows the original comparison with the adapted items. In Item 2, examples of moving around the bed were added to clarify this function. For Item 3, inserting an enema or toileting was added to the words ‘cleaning after defecation or urination’ to define this activity for Thai people. For Item 10, cooking or food preparation, the word “cooking rice” was added to the examples in order to relate with Thai culture. After synthesis and cross adaptation as suggested by the experts, the content validity of the Version 2 IOC was 1.0.
Internal consistency and test-retest reliability
Fifty-four participants (81% males and 19% females) with SCI were recruited. The demographic data of the participants are summarized in Table 2. Most of them had SCI defined by the American Spinal Injury Association Impairment Scale (AIS) A, paraplegia and at a chronic stage of SCI (average post injury time = 11.3 (7.5) years). The SCI-FCS scores ranged from 16 to 53 (possible ranged from 16 to 64).
The overall internal consistency of the SCI-FCS Thai version items was good as indicated by a Cronbach’s alpha coefficient 0.88. The test-retest reliability of the items on the SCI-FCS Thai version was excellent (ICC = 0.99; P < 0.001 for total scores) and ranged from 0.98 to 1 (Table 3). The average length of time between the first assessment and second assessment was 7 days.
Fall concerns in Thai participants with SCI
The SCI-FCS mean scores in each item are presented in Table 3. The items that scored the highest were Item 13: pushing wheelchair up/down gutters or curbs, Item 14: pushing wheelchair up/down a slope, and Item 12: pushing wheelchair on an uneven surface (e.g., rocky ground, irregular pavement).
The SCI-FCS-Thai Version was cross culturally translated through the method of forward and backward translation consistent with guidelines for the process of cross-cultural adaptation of self-report measures of Beaton in 2000 . All SCI-FCS activities were performed by Thai individuals with SCI; however, some activities required more detail to describe the Thai lifestyle. Therefore, three items of the SCI-FCS Thai version were modified to suit the Thai cultural context. In the expert reviews stage of the translation and cross-cultural adaptation process, it was suggested that the phrase “moving around the bed (including sitting up)” was not clear for Thai individuals with SCI, as Thai people with SCI usually perform many activities on their beds. Many of them like to sleep on a mat on the floor and move in many directions. Thus, expanding this activity by including concepts of moving around the bed while in a sitting position, i.e., side to side lying (rolling), sitting up from supine, moving from side to side/forward, and backward while sitting is easier to understand than the original phrase. Therefore, the examples “supine to side lying, moving in each direction while supine or sitting position and sitting up” were added to clarify the functions. In Item 3: inserting an enema or toileting, Thai people usually use the toilet shower or water to clean after defecation or urination. Thus, expanding the word “toileting” to include cleaning the genital/anal area after defecation/urination is clearer for Thai people. Therefore, the phrase “and cleaning after defecation or urination” was added. In Item 10, the original phrase was “cooking or food preparation (e.g., making a sandwich, stirring food on the stove)". Making a sandwich is not a common food preparation for the traditional Thai lifestyle. Rice is usually the main dish for Thai people. Giving more detail to food preparation that relates to the Thai lifestyle is essential. Thus, “cooking rice” was added to this item. After the translated Thai version was adapted, the researchers sent it back to the experts again. They did not have any further suggestions for any of the items. The results showed that all content of the adapted version was clear for Thai individuals with SCI (IOC = 1.0).
The SCI-FCS Thai version has good internal consistency as indicated by a Cronbach’s alpha coefficient 0.88. The results indicated that all translated items measured the same construct as the original items. Previously, the SCI-FCS had been translated into Norwegian, Swedish, and Italian. The original version and all of these translated versions demonstrated good internal consistency (Cronbach’s alpha coefficient ranged from 0.82 to 0.95) [2, 9, 11, 12]. Therefore, the results of this study supported that the items of the SCI-FCS are strongly related to each other. In addition, the SCI-FCS Thai version has excellent test-retest reliability with an ICC of 0.99, indicating that the scores of the SCI-FCS Thai version remain stable after repeated measurements. A high level of test-retest reliability is comparable with the original Australian version (ICC = 0.93) , Norwegian version (ICC = 0.83) , and Italian version (ICC = 0.97) . Therefore, the results of the study supported the consistency when administering the SCI-FCS to assess the concern of falling in Thai individuals with SCI.
The SCI-FCS scores indicated Thai participants with SCI who depend on a manual wheelchair also had concerns of falling when they perform activities of daily living (Mean (SD) = 25.3 (8.1) with a range from 16 to 53 (possible range from 16 = not at all concerned to 64 = very concerned) (Table 2). Interestingly, these scores presented a low level of concern about falling among Thai participants with SCI. Similarly to previous studies of the SCI-FCS, the original version , the Norwegian version , the Swedish version , and the Italian version  showed low mean scores of concern about falling as well, which were 23.0, 22.6, 21.0, and 18.6, respectively. Low mean scores may result from the inclusion of participants who used a manual wheelchair for at least 1 year. Thus, all of them were at a chronic stage of SCI, and likely were more skilled to move and use their wheelchairs in their living situations than individuals who were in the acute or sub-acute stages post-SCI. This agrees with the Norwegian and Italian authors who suggest that the low mean scores in all versions may indicate that the SCI-FCS fails to assess the concern about falling accurately in more high functioning individuals, and that it is better suited for evaluating lower-functioning individuals with SCI [11, 12].
In addition, there are three items on which that Thai participants scored the highest, including Items 13, 14, and 12, respectively (Table 3). These findings are similar to the original and the Swedish versions which reported that these three items were the highest level of concern about falling [9, 10]. In addition, the Norwegian version revealed that Items 12 and 13 had higher scores than the others as well . Pushing the wheelchair up/down gutters or curbs, pushing the wheelchair up/down a slope and pushing the wheelchair on an uneven surface are advanced levels of wheelchair mobility. Fliess-Douer and Vanlandewijck  categorized these functions as obstacle negotiating skills, and the wheelie is an important skill for manual wheelchair users in these activities . Wheelies are considered to occur when the front wheels or caster wheels rise from the surface and the rear wheels stay in contact with the support surface . The individual will shift the body’s center of mass outside the base of support more than that which occurs during basic daily living activities [9, 19]. Since these tasks are difficult to perform, concern about falling in these items scored higher than basic daily skills, such as moving around the bed (Item 2) or washing or showering self (Item 4). In addition, there is a trend toward decreasing length of stay in the hospital for individuals with SCI . As such, individuals might be unable to complete many of the more sophisticated or difficult wheelchair skills at the time of discharge. Therefore, adequate wheelchair skills training during rehabilitation required in order to insure that people with SCI gain the skill and confidence to perform such tasks upon discharge.
The study has some limitations. The criteria excluded individuals using a power wheelchair. There is only a small sample in Thailand that depends on power wheelchairs independently in the community. Moreover, individuals who were recently injured or had lower levels of functioning were not included, thus, this result of the SCI-FCS Thai version may not reflect this population. A further study for evaluating lower-functioning individuals with SCI would be interesting. Another limitation was that we retested the questionnaire within 7 days to assess test-retest reliability. The results showed a high ICC close to 1; and it is possible that the participants may have remembered the questions. A further study that considers a longer time interval is recommended. In addition, it may also be interesting to examine the relation of the SCI-FCS Thai version with other measurements of falls or fall-related psychological affects in individuals with SCI.
The SCI-FCS Thai version is a valid and reliable scale to assess concerns regarding falls in individuals with an SCI who depend on manual wheelchairs. This test can be useful for Thai health professionals to screen fall concern problems in individuals with SCI. The results of fall concerns by using the SCI-FCS Thai version indicated that participants with SCI also had concerns about falling when they perform activities in their daily life.
The datasets generated during and/or analyzed during the current study are available in the supplementary Table 1. And the translated Thai version can be found in the supplementary file: Score sheet of the translated Thai version of the SCI-FCS.
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We would like to thank all of the participants with spinal cord injury and physical therapists who supported this research.
This research was supported by funding from the Faculty of Allied Health Sciences, Thammasat University, Thailand.
Conflict of interest
The authors declare that they have no conflict of interest.
The protocol of the study was approved by the Ethical Review Sub-Committee Board for Human Research Involving Sciences, Thammasat University, No. 3 (ECScTU) number 094/2560.
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Pramodhyakul, N., Pramodhyakul, W. Thai translation and cross-cultural adaptation of the Spinal Cord Injury Falls Concern Scale (SCI-FCS). Spinal Cord 58, 581–586 (2020). https://doi.org/10.1038/s41393-019-0405-y